Hand Sanitizer and Children

Insights from Dr. Jodi Markus

With concerns about the H1N1 swine flu and other infectious diseases, many schools are adding hand sanitizer to their list of required supplies this year. But this policy leads to several questions: What should we look for when selecting a hand sanitizer? Do these products really work? If they do work, will using them create drug-resistant organisms?

No doubt some of you have seen concerning e-mail reports of children becoming gravely ill after ingesting hand sanitizer. I have two school-aged children, and I decided to find the answers before I set out to buy our school supplies.

The Centers for Disease Control and Prevention (CDC) considers hand cleansing the most important thing we can do to avoid getting sick. When our hands come into contact with an object that has been touched by others, such as a doorknob, light switch, or computer keyboard, they pick up many microorganisms. Even though we can’t see them, if we touch our eyes, nose, or mouth, the microorganisms can enter our bodies and cause disease. Good hand hygiene is essential for reducing the transmission of most microorganisms that cause disease.

Because of this, the CDC has issued several recommendations regarding hand hygiene. They have started programs such as the SNAP initiative (School Network for Absenteeism Prevention) for middle schools in an attempt to make hand cleaning throughout the day a high priority. They recommend that visibly soiled hands be washed with soap and warm water for at least 20 seconds.

If the hands are not visibly soiled, alcohol-based hand sanitizer gels are a good alternative. When used properly, they can kill up to 99% of the germs that cause disease. The active ingredient in most hand sanitizers is alcohol, either isopropyl alcohol or ethyl alcohol (ethanol), and most sanitizers contain 62–65%. Such products should contain at least 60% alcohol to be effective and should contain at least 70% for maximum antimicrobial activity.

Alcohol content is a significant consideration. There is at least one commercially available product and several Internet recipes for homemade hand sanitizer that contain 40% alcohol or less. As expected, when these products were tested, they were found to be ineffective as hand cleansers. In fact, they actually made things worse, possibly by spreading the bacteria around and allowing them more room to grow.

The ease of use and alcohol content of such products brings up questions about accidental ingestion. Ethanol is the same type of alcohol found in beer, and isopropyl alcohol is a household staple (commonly called rubbing alcohol). Ingesting a small amount of these products is not fatal, but how much is too much?

According to Heidi Kuhl, a health educator at Central New York Poison Control, ingesting 1 or 2 ounces of alcohol-based liquid hand sanitizer can have grave consequences for a toddler. The University of Maryland School of Pharmacy reports that a hand sanitizer pump dispenses around one-half teaspoonful of product. A toddler who weighs about 30 pounds would need to ingest 8 pumps, or 4 mouthfuls, before requiring medical attention. Hand sanitizers are often brightly colored and include fragrances that may encourage an unattended child to ingest them. If this occurs, contact a poison center immediately.

Because hand sanitizers may contain ethanol, some concern has been raised about the dangers of teenage “recreational ingestion.” The consumption of 2 ounces of a typical ethanol-based hand sanitizer gel is similar to drinking a 2-ounce shot of 120-proof whiskey. In addition, there are some long-term effects, such as liver and brain damage, that can be found in children who continuously ingest small amounts of alcohol-based hand sanitizer.

When used properly, hand sanitizer gels are very safe. When the gel is rubbed into the hands and allowed to dry, the alcohol evaporates and no longer presents a problem for ingestion. When enough gel is used to properly kill organisms, this usually takes about 20 seconds.

According to the Association for Professionals in Infection Control and Epidemiology (APIC), alcohols applied to the skin are among the safest known antiseptics. But will using them actually encourage new, more virulent bacterial strains?

There is very little evidence that antimicrobial resistance to ethanol or isopropyl alcohol develops in the general community. In fact, no mechanism for resistance to alcohol has been described for bacteria. This does not mean it is impossible, however. A recent study found that ethanol had only a 60% killing rate against certain strains of bacteria.

For now, the CDC recommends hand sanitizer gels as a safe and effective way to reduce the transmission of human disease, including flu and cold viruses, fungi, and many different types of bacteria that commonly cause skin, gastrointestinal, and lung disease.

After reading the labels (which I encourage you to do as well!), I found an alcohol-based hand sanitizer gel I was comfortable sending in with my children’s school supplies. I hope this information is helpful to you and wish you a healthy new school year.

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